Creating a community of expert thinkers and learners a toolkit for medical educators
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Creating a Community of Expert Thinkers and Learners A toolkit for medical educators. Amy Fleming, M.D. Introductions. Amy Fleming Introduction of Participants. Conflict of Interest. Amy E. Fleming, M.D. has NO financial relationships to disclose. Goals.

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Creating a community of expert thinkers and learners a toolkit for medical educators

Creating a Community of Expert Thinkers and LearnersA toolkit for medical educators

Amy Fleming, M.D.


Introductions

Introductions

  • Amy Fleming

  • Introduction of Participants


Conflict of interest

Conflict of Interest

  • Amy E. Fleming, M.D. has NO financial relationships to disclose.


Goals

Goals

  • To provide an introduction to core concepts in critical thinking

  • To explore strategies for active teaching of critical thinking in the preclinical and clinical years

  • To build an educator’s tool kit for teaching critical thinking skills


Objectives

Objectives

During the session participants will:

  • Explore core concepts in critical thinking

  • Examine strategies for teaching critical thinking

  • Will develop commitment sheet:

    • Teaching plan for your own practice

    • How to share information with their own faculty.


Expert thinkers

Expert Thinkers

  • Desired outcome of Medical education

    • Excel at “critical thinking”


Expert thinkers1

Expert Thinkers

  • Desired outcome of Medical education

    • Excel at “critical thinking”

  • But, the term “critical thinking” is not mentioned by

    • LCME

    • ACGME

    • UK, UME standards

    • Can MEDS doctor competency framework

      Krupat et al, 2011


Year two curriculum marshall university som

Year two curriculum Marshall University SOM

  • In Year Two, students continue their integration of basic science with clinical medicine in a systems-based curriculum. Students have seven courses which include Approach to Patient Care, Immunology, Microbiology, Advanced Clinical Skills, Pharmacology, Pathology, and Psychopathology. The teaching blocks include Core Concepts, Infectious Organisms and Antimicrobials, Introduction to Neoplasia and Hematology, Nervous System, Cardiovascular System, Pulmonary & Ear, Nose and Throat, Gastrointestinal System, Endocrine and Renal Systems, Musculoskeletal and Genitourinary Systems, and Dermatology, Eye and Toxicology. The curriculum is designed to teach life-long learning and critical thinking skills as students build upon their differential diagnoses with each subsequent block. The Approach to Patient Care course focuses on tying together the instruction from the basic science courses into clinical vignettes, illustrating the challenges and depth of patient care. Through this instruction, the students are prepared to transition more effectively into their clinical years.


Student research at musom

Student Research at MUSOM

  • Research will strengthen your critical thinking skills and fortify your understanding of the basic science concepts. It will ultimately broaden your perspective from bench to bedside.


What is critical thinking

What is Critical Thinking?


What is critical thinking1

What is Critical Thinking?

  • “The intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing, and/or evaluating information…” -Scriven and Paul, 2010

  • “concerned with reason, intellectual honesty, and open-mindedness as opposed to emotionalism, intellectual laziness, and close-mindedness.” -Kurland, 1995


Critical thinking

Critical Thinking

Evaluating information

Evaluating our own thought

In a disciplined way.


Our brand of critical thinking clinical reasoning

Our brand of Critical thinking:Clinical Reasoning

Clinical Pathophysiology Made Ridiculously Simple

Aaron Berkowitz


Krupat medical teacher 2011

Krupat Medical Teacher 2011

Critical Thinking:

  • A Process: of synthesis and analysis

  • A skill or ability

  • Characteristics of the individual, personality traits, habits of mind: (careful attention, curiosity, courage, thinking deeply/openly, awareness of self and others)


Krupat medical teacher 20111

Krupat Medical Teacher 2011

  • Engage in data gathering:

    • H&P, go to literature, order tests, consult with experts

  • Integrate, organize, synthesize, utilize information:

    • define and explore all causes, weigh risks/benefits, prioritize

  • Communicate with Patients:

    • Show respect, inform and involve patients

  • Make Decisions and Take action:

    • use best available evidence, ensure information is complete, make plans for follow up

  • Act in ways that are self-reflective:

    • recognize uncertainties, doubts, limits of knowledge, biases. Understand that one might be wrong.


Perkins conceptual framework good thinking

Perkins: conceptual frameworkGood Thinking

  • Sensitivity: awareness of flow of events, need for more information, value of understanding alternatives

  • Inclination: committed to invest the effort in thinking the matter through

  • Ability: knowledge, skills, how to frame questions, integrate information, apply one’s knowledge


What is critical thinking2

What is Critical thinking?

  • How can we foster a climate throughout our university that is focused on the development of thinking abilities?

  • “Critical thinking is not something to be devoured in a single sitting nor yet in a couple of workshops. It is to be savored and reflected upon. It is something to live and grow with, over years, over a lifetime.”

  • a teachable cognitive skill independent of specific knowledge


How did you learn critical thinking

How did you learn critical thinking?

www.media.photobucket.com


How did you learn critical thinking1

How did you Learn Critical Thinking?

  • Often not “taught”

  • Practice, experience

  • Unconscious learning

  • Talking out loud

  • By being challenged with questions… why? What are you thinking?

  • Expert modeling


4 stages of competence

4 Stages of Competence

  • Unconscious Incompetence

    • Do not recognize the deficit

    • Neither understand nor know how to do something

  • Conscious Incompetence

    • Realize you don’t know

  • Conscious Competence

    • Understand/know how to do something, but demonstrating the skill/knowledge requires concentration/consciousness

  • Unconscious Competence

    • Second nature, like riding a bike

    • Hard to teach/break down this automatic thinking

      1940's psychologist: Abraham Maslow


5 th stage of competence

5th Stage of Competence

If unconscious competence is the top level, then how on earth can I teach critical thinking?

  • Reflective competence -David Baume, May 2004

  • Conscious competence of unconscious competence

  • Superconscious Meta-competence

    • Move beyond thinking intuitively and are able to teach in a very deliberate way

    • Person's ability to recognize and develop unconscious competence in others


Stages of competence

Stages of Competence

Courtesy of Will Taylor, Chair, Department of Homeopathic Medicine, National College of Natural Medicine, Portland, Oregon, USA, March 2007


Creating a community of expert thinkers and learners a toolkit for medical educators

BUT…

by Sidney Harris


Tool kit

Tool Kit:

  • Priming and Framing

  • Learning Script

  • Active Observation

  • One Minute Preceptor

  • SNAPPS

  • Illness Scripts


Priming

Priming

  • Provide patient-specific information before learner enters the room

    • “4-year old boy with global developmental delay, a congenital heart defect, and respiratory distress.”

  • Prepare the learner for the encounter by asking case-based questions

    • What should you ask to understand the respiratory distress?

    • What will you ask regarding the congenital heart defect history?


Framing

Framing

  • Tell the learner what should be accomplished during the visit and how long it should take

  • “This child has a history of global developmental delay and congenital heart disease but is being admitted for respiratory distress. Focus on the evaluation for the respiratory distress acutely. Make sure to cover his history of heart disease as it pertains to his acute presentation. Don’t dwell on the developmental history. Spend about 30-45 minutes on the H and P, then come find me.”


Creating a community of expert thinkers and learners a toolkit for medical educators

Priming


Creating a community of expert thinkers and learners a toolkit for medical educators

Framing


Priming and framing

Priming and Framing

  • Shadowing

  • Standardized Patients:

    • Hypothesis-Driven Physical Exam

      • (1) orientation, (2) anticipation, (3) preparation, (4) role play, (5) discussion-1, (6) answers, (7) discussion-2, (8) demonstration and (9) reflection. Nishigori, Bordage, et al: Medical Teacher, Feb 2011.

        Eva, Bordage, et al: Med Educ. Aug 2010.

  • Independent Learners

    • Quick search on chief complaint


Priming and framing1

Priming and Framing

  • Priming: Comprehensive knowledge of the gross and microscopic structure of the human body to provide  an anatomical basis  for disease presentations. 

  • Framing: To introduce CT scans, and the interpretation of anatomy as visualized by this technique.


Learning script

Learning Script

  • Works best when a presentation is involved.

  • After participating in activity (histology lab, on call autopsy, case discussion, oral presentation on rounds) learner writes 2-3 things that s/he wants to learn on an index card

  • Learner gives card to teacher and then presents

  • During presentation, teacher can address issues or questions on card or they can wait until later.

  • At completion of case, return card to learner

  • Learner picks 1 or 2 issues to research. Follow up next time!


Learning script1

Learning Script

  • Learner centered

  • Teacher doesn’t have to anticipate learner needs

  • Expectation that learner will have questions

  • Emphasizes curiosity, questioning, learner motivation

  • Allows teaching at multiple levels


Active observation

Active Observation

  • Can be used for learners with little to no medical training, such as undergraduates

  • Can be used in large case settings, lectures, clinical shadowing, critical situations (codes)

  • Explain rationale for focused observation (medical anthropologist)


Active observation1

Active Observation

  • Tell learner what to observe:

    • 3 columns on 3x5 card

    • See - Reaction - Why

    • Review what is written on card after the experience

    • Learner can also write questions on the card

  • Give feedback on observations

  • Excellent mechanism for teaching at the level of the learner

  • Allows teaching on “attitudes”, professionalism, communication


Active observation2

Active Observation


Active observation colloquium

Active Observation: colloquium


One minute preceptor

One Minute Preceptor

  • Learner has presented encounter with patient

  • Get a commitment from learner

    • “What do you think is going on?”

  • Probe for supporting evidence (reasoning)

    • “What led you to that conclusion?”

    • “Did you consider alternatives?”


One minute preceptor1

One Minute Preceptor

  • Reinforce what was done well

    • “Your diagnosis of X was well supported by Y”

  • Identify omissions or correct errors

    • “Although your suggestion is possible, in a situation like this I think that Z is more likely because…”

  • Teach general principles and next learning steps

    • Help learner build foundations and structure for future questions.


Snapps

SNAPPS

Learner-centered model in which the learner:

  • SUMMARIZES briefly the history and findings

  • NARROWS the differential to 2-3 possibilities

  • ANALYZES the differential by comparing and contrasting the possibilities

  • PROBES the preceptor by asking questions about uncertainties, difficulties, or alternative approaches

  • PLANS management for the patient

  • SELECTS a case-related issue for self-directed learning

    Wolpaw


Illness scripts

Illness Scripts

  • Breaking down the way physicians approach clinical reasoning to a very basic level.

  • The patient who “read the book.”


Practice problem representation

Practice Problem Representation

  • 18yo woman


Practice problem representation1

Practice Problem Representation

  • 18yo woman

  • Admitted for acute abdominal pain.


Practice problem representation2

Practice Problem Representation

  • 18yo woman

  • Admitted for acute abdominal pain.

  • Has associated anorexia


Practice problem representation3

Practice Problem Representation

  • 18yo woman

  • Admitted for acute abdominal pain.

  • Has associated anorexia

  • Initial pain peri-umbilical, now localized in RLQ


Practice problem representation4

Practice Problem Representation

  • 18yo woman

  • Admitted for acute abdominal pain.

  • Has associated anorexia

  • Initial pain peri-umbilical, now localized in RLQ

  • Has rebound tenderness and pain over McBurney’s point


Illness script

Illness Script

  • 8yo boy


Illness script1

Illness Script

  • 8yo boy

  • Admitted for acute abdominal pain and poor PO intake.


Illness script2

Illness Script

  • 8yo boy

  • Admitted for acute abdominal pain and poor PO intake.

  • Has a purpuric rash in a waist-down distribution.


Illness script3

Illness Script

  • 8yo boy

  • Admitted for acute abdominal pain and poor PO intake.

  • Has a purpuric rash in a waist-down distribution.

  • Presents with proteinuria and large joint pain.


Illness script4

Illness Script

  • 8yo boy

  • Admitted for acute abdominal pain and poor PO intake.

  • Has a purpuric rash in a waist-down distribution.

  • Presents with proteinuria and large joint pain.

    • Henoch Schonlein Purpura


Physician reasoning

Physician Reasoning

  • Physicians essentially use 2 modes of thinking:

    • Pattern Recognition:

      • Clinician has seen the problem before

      • Fast (<10 sec), automatic, largely accurate

    • Analytical Thinking:

      • Clinician is puzzled or can’t find the pattern

      • Slower and more conscious process

        Norman et al (1989 and 1992)


Illness scripts1

Illness Scripts

  • Expert clinicians store and recall knowledge as diseases, conditions or syndromes – “illness scripts” – that are connected to problem representations

  • These representations trigger clinical memory permitting the related knowledge to become accessible for reasoning

  • Knowledge recalled as illness scripts has a predictable structure:

    • The predisposing conditions

    • The pathophysiological insult

    • The clinical consequences

      Judith Bowen, NEJM 2006


Resident expert vs medical student novice

Resident (expert) vs Medical student (novice)

  • Expert: has seen similar case before

    • Forms an early impression (mental abstraction) of the patient’s story

    • Asks a series of guided questions and performs a focused exam

    • Searches for information that can be used to discriminate among different diagnostic explanations

    • Gives a succinct presentation, transforms the patient’s story into a meaningful clinical problem

  • Novice: has never seen case before

    • Asks a broad range of questions and performs an extensive exam

    • Try to solve the problem without building a problem representation (too close to the details to see the big picture)

    • Students are better at interpreting available findings than selecting useful ones.

      Judith Bowen NEJM 2006


Illness scripts2

Illness Scripts

  • Enter with multiple hypotheses

    • Discriminating features

  • Gather additional data

  • Problem Representation

    • Synthesize into the big picture (one liner)

  • Select Illness Script for working diagnosis

  • Verify working diagnosis

Judith Bowen NEJM 2006


Problem representation

Problem Representation

  • Summarizes the specific case in abstract terms

  • Uses semantic qualifiers

    • Paired, opposing descriptions that can be used to compare and contrast diagnoses

      • Last night  acute

      • Right knee  single large joint

  • Links stored knowledge with the current clinical case

    • Bowen NEJM 2006, Bordage Acad Med 1999


Appendicitis case

Appendicitis Case

Problem representation for our patient

  • 18yo woman

  • Admitted for acute abdominal pain.

  • Has associated anorexia

  • Initial pain peri-umbilical, now localized in RLQ

  • Has rebound tenderness and pain over McBurney’s point


Appendicitis case1

Appendicitis Case

  • Caitlyn is an otherwise healthy 18yo who presents with acute, severe, localized RLQ abdominal pain, anorexia, and nausea, with an exam concerning for acute abdomen.


Creating a community of expert thinkers and learners a toolkit for medical educators

Semantic (Abstract) Qualifiers

Cognitive Biases (Diagnostic Pause)

-Anchoring bias

-Confirmation bias

-Premature diagnosis closure

-Availability bias

-Representativeness bias

Clinical consequences – Distinguishing features & progression of the disease?

Bordage G, Acad Med 1999

Bowen JL. NEJM 2006

T.J. Jirasevijinda


Creating a community of expert thinkers and learners a toolkit for medical educators

Semantic (Abstract) Qualifiers

Acute

1st presentation

Mild

Diffuse

Non-surgical abdomen

Chronic

Recurrent

Severe

Localized

Acute Abdomen

Cognitive Biases (Diagnostic Pause)

-Anchoring bias

-Confirmation bias

-Premature diagnosis closure

-Availability bias

-Representativeness bias

Clinical consequences – Distinguishing features & progression of the disease?

Bordage G, Acad Med 1999

Bowen JL. NEJM 2006

T.J. Jirasevijinda


Creating a community of expert thinkers and learners a toolkit for medical educators

Semantic (Abstract) Qualifiers

Acute

1st presentation

Mild

Diffuse

Non-surgical abdomen

Chronic

Recurrent

Severe

Localized

Acute Abdomen

Cognitive Biases (Diagnostic Pause)

-Anchoring bias

-Confirmation bias

-Premature diagnosis closure

-Availability bias

-Representativeness bias

Clinical consequences – Distinguishing features & progression of the disease?

Severe acute abdominal pain

periumbilical moving to McBurney’s point

Nausea, Vomiting, Anorexia

Fever, possible sepsis

Peritoneal signs, Surgical abdomen

Bordage G, Acad Med 1999

Bowen JL. NEJM 2006

T.J.


Attending example

Attending Example


Verify the diagnosis

Verify the Diagnosis

  • Does the diagnosis make sense?

  • Does the diagnosis explain all the H&P findings?

  • What features remain confusing?

  • Do I need to acquire more data?


Illness scripts3

Illness Scripts

Diagnostic Pause

Diagnosis

Modified from Judith Bowen 2006


Cognitive bias pitfalls

Cognitive Bias Pitfalls

  • Availability Bias: the diagnosis is easily recalled; depends on frequency of what you have seen in the past (Non-availability bias: out of site, out of mind…)

  • Representativeness Bias: it looks like a duck, walks like a duck, so it is a duck

  • Anchoring Bias: too much reliance on one piece of information / data

  • Confirmation Bias: seek info to confirm your initial impression, weigh evidence favoring diagnosis more heavily

  • Premature Diagnostic Closure: reaching a diagnosis and failing to assimilate additional information that contradicts it

    Croskerry 2002, Bordage 1999


Teaching this to others

Teaching this to Others

  • General principles of effective faculty development activities:

    • Participants should identify a learning gap ahead of time.

    • Sessions that are interactive + didactic are more effective than either alone.

      -Consider having faculty work in groups, as opposed to individuals.

      from O’Sullivan and Irby, Reframing Research on Faculty Development, Academic Medicine, April 2011


Teaching this to others1

Teaching this to Others

  • Principles of effective faculty development:

    - Faculty should commit to a behavior change before leaving.

    • They should plan to do PDSA cycles on this behavior change

    • They should leave with a plan to measure their efficacy (consider accountability or check-ins)

    • from O’Sullivan and Irby, Academic Medicine, April 2011


Make a personal plan

Make a Personal Plan

  • Write down one or two tools you will try in your practice in the next month

    • Which tool will you try?

    • Why did you choose this tool?

    • How will you utilize it?

    • What challenges do you anticipate to using it?

    • How will you measure its success/failure?


Tool kit1

Tool Kit:

  • Priming and Framing

  • Learning Script

  • Active Observation

  • One Minute Preceptor

  • SNAPPS

  • Illness Scripts


Summary of goals

Summary of Goals

  • To provide an introduction to core concepts in clinical reasoning

  • To explore strategies for active teaching of clinical reasoning in the clinic and at the bedside

  • To build an educator’s tool kit for teaching and evaluating their student’s clinical reasoning skills


Review of workshop objectives

Review of workshop objectives

During the session participants will:

  • Explore core concepts in clinical reasoning

  • Apply strategies for teaching clinical reasoning

  • Analyze students’ clinical reasoning skills in oral presentations


Creating a community of expert thinkers and learners a toolkit for medical educators

  • "Education would be much more effective if its purpose was to ensure that by the time they leave school every boy and girl should know how much they do not know, and be imbued with a lifelong desire to know it." 

    • William Haley, British Editor


Creating a community of expert thinkers and learners a toolkit for medical educators

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